Osteoarthritis treatment

 

Author
Kenneth C Kalunian, MD
Section Editor
Peter Tugwell, MD
Deputy Editor
Paul L Romain, MD

Disclosures

ARTHRITIS INTRODUCTION — Osteoarthritis (OA), also called arthritis, is a painful condition caused by a gradual loss of cartilage from the joints and, in some people, joint inflammation (figure 1). Arthritis can affect almost any joint, although it occurs most frequently in the hands, knees, hips, and spine. Common symptoms include pain, stiffness, and difficulty moving the joint easily.

Arthritis is a chronic condition that gradually worsens over time. However, arthritis treatment can often reduce your symptoms, allow you to stay active, and possibly slow the progression of this condition. Treatment includes a combination of nonpharmacologic therapies (therapies other than drug therapy) and drug therapy and in some cases, surgery.

Arthritis treatment is tailored to you, including how severe your pain and stiffness are, which joints are affected by arthritis, and how well a particular treatment works. It is important to work with a healthcare provider to create an effective and acceptable long-term plan for living with arthritis.

This topic review discusses arthritis treatments. A separate article discusses arthritis symptoms and how it is diagnosed. (See “Patient information: Osteoarthritis symptoms and diagnosis”.)

OSTEOARTHRITIS TREATMENT WITHOUT MEDICATIONS — There are a number of treatments other than medications. These can substantially improve your arthritis symptoms, and they are usually the first arthritis treatments recommended.

Rest — Arthritis symptoms are typically worsened by activity and improved with rest. However, a complete lack of activity can lead to a loss of muscle and joint stiffness. If arthritis flares and causes significant pain and inflammation, your healthcare provider may recommend rest for 12 to 24 hours, followed by a return to usual activities.

Weight loss — Obesity is strongly linked to the development of arthritis of the knee. Weight loss, even modest weight loss, appears to lower this risk. It is not yet known if weight loss slows the worsening of arthritis in joints that are already affected. However, weight loss may reduce joint pain from weight-bearing joints, such as the hips and knees. (See “Patient information: Weight loss treatments”.)

Physical therapy and exercise programs — Physical therapy and exercise improve flexibility and strengthen the muscles surrounding the joints. People who exercise regularly despite their arthritis will typically have less pain and better function than those who are inactive. A separate article discusses exercise and arthritis. (See “Patient information: Arthritis and exercise”.)

Orthoses — Orthoses are devices that help to keep the joints aligned and functioning correctly. There are many different types of orthoses that can reduce symptoms and help maintain function in people with osteoarthritis.

Well-cushioned shoes and orthotic shoe inserts may reduce stress on the joints of the spine and leg.
Splints that immobilize the joints can reduce pain and inflammation, and many splints can be worn throughout the day and night. Braces can help stabilize unstable joints.
Assistive devices — Canes, walkers, electric powered seat lifts, raised toilet seats, and tub and shower bars can reduce the stress on joints and make it easier to perform daily tasks. A physical therapist may suggest these and other assistive devices, depending upon the severity and location of your arthritis.

Vitamins — Studies have linked certain vitamins to joint health, but the role of vitamins in arthritis treatment is still uncertain. Osteoarthritis is less likely to worsen in people who have a high dietary intake of vitamin C (ascorbic acid) and a high dietary intake and high blood levels of vitamin D. However, it is unknown if supplementation with these vitamins has the same effects, or if high dietary intakes of vitamins can prevent the onset of osteoarthritis. (See “Patient information: Calcium and vitamin D for bone health”.)

Heat and cold therapies — Applying heat and cold to arthritic joints can help to control arthritis symptoms such as pain and stiffness.

Heat therapy — Heat relieves pain and stiffness in arthritic joints. Heat can be applied to the joints with hot packs, hot water bottles, heating pads, or electrically heated mittens.
It is important to avoid burning the skin with heat therapy. To avoid burns, hot water bottles should be filled with warm, not boiling, water. Heating pads should be set on a timer and used for no more than 20 minutes at a time. The heating pad can be reapplied after 20 minutes of no use.

Cold therapy — Cold relieves pain in arthritic joints and reduces muscle spasms. Cold can be applied for short periods using ice packs or coolant sprays. People with certain medical conditions, such as the Raynaud phenomenon, should not use cold therapy.
Transcutaneous electrical nerve stimulation (TENS) — A TENS unit delivers a mild electrical current to the skin, stimulating nerve fibers in the skin that may interfere with the transmission of pain signals from the arthritic joint.

The use of TENS as an arthritis treatment is controversial. Some studies have found that those who use TENS for arthritis of the knee have reduced knee pain, a greater ability to bend the knee, and a reduced duration of morning stiffness. However, another study found that TENS was no more effective for relieving pain than the drug naproxen (Aleve®, Anaprox®) or a placebo.

Arthritis education and support — Chronic arthritis can be hard, both physically and psychologically. Arthritis symptoms may cause you to feel frustrated, dependent upon others for help, and even depressed. These factors may reduce your motivation to stick with arthritis treatment.

By learning more about osteoarthritis, you can better participate in your own care. It is important to discuss the options for the treatment of arthritis, the effects of arthritis on daily activities, and strategies for coping with the limitations imposed by arthritis with your healthcare provider.

Some studies suggest that psychosocial support may be as effective as drug therapy for reducing the symptoms of arthritis. Support can be achieved by building an informal support network or by participating in formal arthritis support group. Information about these groups is available below (see ‘Where to get more information’ below).

Other therapies — Several other therapies have been evaluated to determine if they have any effect on osteoarthritis. (See “Investigational approaches to the pharmacologic therapy of osteoarthritis”.)

Dietary supplements — Glucosamine and chondroitin are dietary supplements that have received a lot of attention for their potential benefit in reducing pain and slowing the progression of arthritis.

Glucosamine — Glucosamine HCL was no more effective in relieving arthritis pain or improving function than placebo in a well designed controlled trial; it is possible that other formulations may be effective. Glucosamine does not appear to slow the worsening of arthritis over the long term [1]. There are few side effects of glucosamine; it should not be used by patients who are allergic to shellfish.
Chondroitin — Chondroitin used alone appears to provide little benefit for people with osteoarthritis. There are no significant side effects of chondroitin.
The combination of glucosamine and chondroitin sulfate has not proven to be better than placebo for pain relief or functional improvement in patients with OA of the knee [2].

Traditional Chinese medicine — Several components of traditional Chinese medicine, including herbs and acupuncture, may help control the arthritis symptoms in some people, although the benefits of these therapies have not been confirmed in large well designed clinical studies.

Reumalex, willow bark, stinging nettle, Articulin F, devils claw, extract of soybean and avocado unsaponifiables (ASU), and Phytodolor may improve arthritis pain, while other herbs and combinations, such as Eazmov, Gitadyl, or ginger extract are probably ineffective. If you are considering using herbal medicines, talk to your healthcare provider.

Capsaicin cream — Some people experience relief of arthritis pain when they apply creams containing capsaicin, the active substance in hot chili peppers. Capsaicin depletes a pain-causing substance in nerve endings and lessens the arthritis pain by about 30 percent in some people. Forty percent of people experience side effects when using capsaicin cream, including burning, stinging, and redness of the skin.

Applying substances such as dimethylsulfoxide (DMSO) or using low power laser light, copper bracelets, or magnets are of questionable benefit. Chiropractic manipulation, acupressure, biofeedback, and homeopathy are popular, but also have unproven benefits for arthritis symptoms.

OSTEOARTHRITIS TREATMENT WITH MEDICATIONS — Drug therapy is a key component of an arthritis treatment plan. Many types of drugs are available. More detailed information is available separately. (See “Pharmacologic therapy of osteoarthritis”.)

Pain relief medications — Analgesics relieve pain but do not have any effect on inflammation. These drugs are often recommended when arthritis pain does not respond to nonpharmacologic measures. Drugs in this class include acetaminophen and opioid (narcotic) analgesics.

Acetaminophen (Tylenol® and others) can relieve mild to moderate arthritis pain. To avoid the serious but rare side effect of liver damage due to acetaminophen, it is important to follow dosing instructions and avoid drinking excessive amounts of alcohol.

The pain of sudden, severe arthritis exacerbations may require treatment with narcotic analgesics such as codeine. Narcotics should be taken for only short periods of time because they can be addictive. They are often most effective when taken together with nonsteroidal anti-inflammatory drugs (NSAIDs). Narcotics can also be combined with acetaminophen (eg, Tylenol 3 contains acetaminophen-codeine).

Nonsteroidal anti-inflammatory drugs — Nonsteroidal anti-inflammatory drugs (NSAIDs) relieve pain and reduce inflammation. Many of the nonprescription products that are available for treating arthritis pain are NSAIDs. These drugs are often recommended before analgesics for people who have osteoarthritis and evidence of inflammation. They are also recommended for some people with noninflammatory OA who do not get adequate pain relief with simple analgesics. NSAIDs are discussed in detail in a separate topic review. (See “Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)”.)

Joint injections — Two types of injections are used for people with arthritis pain: glucocorticoid (steroid) injections and injections of a liquid known as hyaluronate.

Glucocoticoid (steroid) injections — Glucocorticoids can suppress inflammation and relieve arthritis symptoms when injected into arthritic joints.

Glucocorticoid injections may be recommended for people who have osteoarthritis confined to a few joints and who still have pain despite the use of NSAIDs. Glucocorticoid injections may also be recommended for people with osteoarthritis who cannot take NSAIDs.

Joint injections have few side effects, but some people experience a brief flare of arthritis symptoms after an injection. There is also a small risk of joint infection. (See “Patient information: Joint infection”.)

Glucocorticoids may damage certain joints when injected frequently. Therefore, clinicians recommend no more than three to four injections per year for weight-bearing joints such as the knees.

Hyaluronate injections — Normal joint fluid contains a large amount of hyaluronate, which allows the joint fluid to be slippery. Synthetic hyaluronates may be injected into the knee to treat arthritis. After the injection, pain relief may last for several months. Hyaluronan (Hyalgan®) and hylan-GF-20 (Synvisc®) are two products that can be used that have similar effects. These agents are generally injected in the knee, but their use in other joints is being studied.

Joint inflammation has occasionally occurred after this type of injection. As with steroids, there is a small risk of infection. Thus, if you develop severe joint pain after an injection, call your healthcare provider immediately.

Hyaluronate injections are generally reserved for people with osteoarthritis who cannot take NSAIDs or who do not get adequate pain relief with them. People awaiting joint surgery may benefit from these injections.

Colchicine — This drug is often recommended for people with inflammatory osteoarthritis that does not improve with nonpharmacologic therapies and NSAIDs. A clinician may recommend colchicine for people who have frequent flares of osteoarthritis that is resistant to other treatments.

Hydroxychloroquine — Hydroxychloroquine (Plaquenil®) has immune-modulating effects that reduce the inflammation of arthritis in some people. This drug may be recommended for people with severe inflammatory OA and those who have bone damage related to osteoarthritis.

JOINT IRRIGATION — During joint irrigation, the joint space is flushed with fluid to remove cartilage debris, irritating crystals, and other substances. In some people with OA, irrigation may reduce joint pain, stiffness, and tenderness, and allow for increased physical activity.

OSTEOARTHRITIS SURGERY — Surgery is usually reserved for severe arthritis that significantly limits your activities and does not respond to other arthritis treatments. (See “Patient information: Total knee replacement (arthroplasty)”.)

However, surgery is recommended before arthritis causes complications such as muscle loss and joint deformities. Furthermore, those who undergo surgery should be in the best possible physical condition and prepared for rehabilitation after surgery.

More detailed information about surgery for arthritis is available separately. (See “Surgical therapy of osteoarthritis”.)

Arthroscopic treatment

Arthroscopic synovectomy — Arthroscopic synovectomy is the surgical removal of the synovium (the joint lining) using an arthroscope (a thin lighted tube) that is inserted into the joint. Inflammation of the synovium appears to play a key role in arthritis in some people. Synovectomy may be recommended for people who have inflammatory osteoarthritis that does not respond to other measures.

Arthroscopy and joint irrigation — The benefit of arthroscopic surgery in people with arthritis is controversial. In one study, patients who had “real” arthroscopic treatment and joint irrigation were compared to others who had a “sham” procedure [3]. Those who had the “sham” surgery were taken to the operating room where the doctor simulated arthroscopic surgery (but did not perform the actual procedure). Post-procedure improvement in symptoms was similar in both groups.

A selected group of patients with arthritis may benefit from arthroscopy. However, people with significant arthritis are more likely to benefit from other types of surgery.

Realignment — Surgery may be used to realign bones and other joint structures that have become misaligned because of long-standing arthritis. For the knee, realignment may shift weight bearing to healthier cartilage to relieve arthritis pain. This type of alignment may be recommended for younger and more active patients instead of joint replacement surgery.

Fusion — Surgery may be used to permanently fuse two or more bones together at a joint. This may be recommended for badly damaged joints for which joint replacement surgery is not appropriate. Fusion may be recommended for joints of the wrist and ankle and the small joints of fingers and toes.

Joint replacement — Surgery may be used to replace a damaged joint with an artificial joint. The most common reason for having joint replacement surgery is when pain is not controlled by a combination of nonpharmacologic and drug treatments.

Joint replacement surgery dramatically relieves pain in people with severe arthritis of the hip or knee, and this benefit appears to last for at least three years. However, it may take up to one year before the benefits of joint replacement surgery become fully apparent.

For more information about joint replacement, (see “Patient information: Total knee replacement (arthroplasty)” and “Patient information: Total hip replacement (arthroplasty)”).

Cartilage grafting — Surgery may be used to graft new cartilage cells into damaged regions of cartilage. At this time, the benefits of cartilage grafting in arthritic joints is still being studied. Cartilage grafting is likely to be most practical when the cartilage damage is confined to a very small area that is surrounded by normal cartilage. Current techniques are not helpful for people with large areas of thin or absent cartilage.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Osteoarthritis symptoms and diagnosis
Patient information: Weight loss treatments
Patient information: Arthritis and exercise
Patient information: Calcium and vitamin D for bone health
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)
Patient information: Joint infection
Patient information: Total knee replacement (arthroplasty)
Patient information: Total hip replacement (arthroplasty)

Professional Level Information:

Clinical manifestations of osteoarthritis
Diagnosis and classification of osteoarthritis
Evaluation of the adult patient with knee pain
Evaluation of the adult with hip pain
Evaluation of the patient with hand pain
Evaluation of the patient with neck pain and cervical spine disorders
Glenohumeral osteoarthritis
Investigational approaches to the pharmacologic therapy of osteoarthritis
Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis
Musculoskeletal complications in diabetes mellitus
Nonpharmacologic therapy of osteoarthritis
Pathogenesis of osteoarthritis
Patient guidelines for weight-resistance training in osteoarthritis
Pharmacologic therapy of osteoarthritis
Risk factors for and possible causes of osteoarthritis
Surgical therapy of osteoarthritis
Weight-resistance training in patients with osteoarthritis

The following organizations also provide reliable health information.

National Library of Medicine
(www.nlm.nih.gov/medlineplus/arthritis.html, available in Spanish)

National Institute of Arthritis and Musculoskeletal and Skin Diseases
(301) 496-8188
(www.niams.nih.gov/Health_Info/Arthritis/default.asp)

National Institute on Aging
(www.nia.nih.gov/HealthInformation/Publications/arthritis.htm, available in Spanish)

American College of Rheumatology
(404) 633-3777
(file://www.rheumatology.org/practice/clinical/patients/index.asp)

The Arthritis Foundation
(800) 283-7800
(www.arthritis.org)

Patient Support — There are a number of online forums where patients can find information and support from other people with similar conditions.

About.com Arthritis Forum
(file://arthritis.about.com/forum)

 

REFERENCES
Rozendaal RM, Uitterlinden EJ, van Osch GJ, et al. Effect of glucosamine sulphate on joint space narrowing, pain and function in patients with hip osteoarthritis; subgroup analyses of a randomized controlled trial. Osteoarthritis Cartilage 2009; 17:427.
Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med 2006; 354:795.
Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347:81.
Katz JN, Mahomed NN, Baron JA, et al. Association of hospital and surgeon procedure volume with patient-centered outcomes of total knee replacement in a population-based cohort of patients age 65 years and older. Arthritis Rheum 2007; 56:568.
Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000; 43:1905.